Exhibits here

Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Poor personal hygiene

Over sedation

Bruises in various stages of healing

Depression or withdrawn behavior

Untreated pressure injuries

Leaving an older adult in a public space

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"B"}}

1. Poor personal hygiene

- Neglect: X

Rationale: Poor personal hygiene indicates neglect, as the caregiver is not providing adequate care for the client's basic needs.

2. Over sedation

- Physical abuse: X

Rationale: Over sedation is consistent with physical abuse because it involves administering medication to subdue the client, potentially to control or silence them.

3. Bruises in various stages of healing

- Physical abuse: X

Rationale: Bruises in various stages of healing are a sign of physical abuse, indicating that the client has been physically harmed multiple times over a period.

4. Depression or withdrawn behavior

- Mistreatment: X

Rationale: Depression or withdrawn behavior can be a result of mistreatment, which includes emotional and psychological abuse, leading to social isolation and emotional distress.

5. Untreated pressure injuries

- Neglect: X

Rationale: Untreated pressure injuries are a clear sign of neglect, as the caregiver is failing to provide necessary medical care to prevent and treat these injuries.

6. Leaving an older adult in a public space

- Mistreatment:

Rationale: Abandonment, which is a form of mistreatment, involves leaving the older adult in a public space without care or supervision.

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Correct Answer is B

Explanation

A. Initiating teaching for client care after discharge is incorrect. Teaching, especially initial or comprehensive education, is within the scope of practice of a registered nurse (RN), not a practical nurse (PN).
B. Using bladder ultrasound to detect urinary retention is correct. This is a task within the scope of practice for a PN, as it involves data collection and does not require independent clinical judgment.
C. Completing comprehensive assessments is incorrect. Comprehensive assessments require critical thinking and are the responsibility of the RN. PNs may collect data but do not perform initial comprehensive assessments.
D. Beginning initial sterile wound care for surgical clients is incorrect. The RN should perform the first sterile dressing change postoperatively to assess the wound properly. The PN may perform subsequent dressing changes per facility policy.

A. Every 5 minutes for 30 minutes, then every 4 hours thereafter. B. Every 5 minutes for one hour. C. Every 15 minutes for one hour, then every 1 hour for 2 hours. D. Every 1 hour for 2 hours.

Correct Answer is A

Explanation

A. Every 5 minutes for 30 minutes is crucial after paracentesis to closely monitor for signs of hypovolemia, such as a sudden drop in blood pressure. After this initial intensive monitoring period, the frequency can be reduced to every 4 hours to assess for any delayed effects or complications.

B. Every 5 minutes for one hour is a shorter duration of monitoring compared to option A and

may not provide adequate time to detect and respond to any significant changes in blood pressure that could occur after paracentesis, especially considering the volume of fluid removed.

C. Every 15 minutes for one hour, then every 1 hour for 2 hours provides frequent monitoring

initially, but the interval between assessments is too long after the first hour, potentially missing early signs of complications such as hypovolemia.

D. Every 1 hour for 2 hours does not provide sufficient frequency of monitoring, especially during the critical immediate post-paracentesis period when rapid changes in blood pressure can occur. This schedule may delay the detection and management of complications.

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Exhibits here Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?

Correct Answer is B

Explanation

A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

Correct Answer is A

Explanation

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

A school-aged client was recently diagnosed with type 1 diabetes mellitus. Which symptom did the client's parents most likely report?

In providing nursing care for a client after gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

The nurse who is working in the emergency department is obtaining evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most important for the nurse to implement?

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?

To auscultate for a carotid bruit, the nurse places the stethoscope at what location (Select the correct location on the image. To change, click on a new location.)

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Exhibits here

Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.